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Massachusetts General Hospital

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JACC-Cardiovasc. Imag., Feb 12 2025, S1936-878X(25)00028-2 | https://doi.org/10.1016/j.jcmg.2024.12.004 Vulnerable or High-Risk Plaque: A JACC: Cardiovascular Imaging Position Statement

Rocco Vergallo MD, PhD ^a,b, Seung-Jung Park MD, PhD ^c, Gregg W. Stone MD ^d, David Erlinge MD, PhD ^e, Italo Porto MD, PhD ^a,b, Ron Waksman MD^f, Gary S. Mintz MD ^g, Fabrizio D’Ascenzo MD, PhD ^h, Sara Seitun MD ^a, Luca Saba MD ⁱ, Rozemarijn Vliegenthart MD, PhD ^j, Fernando Alfonso MD ^k, Armin Arbab-Zadeh MD, PhD, MPH ^l, Peter Libby MD ^m, Marcelo F. Di Carli MD ^m, James E. Muller MD ^m, Gerald Maurer MD ⁿ, Robert J. Gropler MD ^o, Y.S. Chandrashekhar MD ^p, Eugene Braunwald MD ^m, Valentin Fuster MD, PhD ^d, Ik-Kyung Jang MD, PhD^q

^aIRCCS Ospedale Policlinico San Martino, Genoa, Italy
^bUniversità di Genova, Genoa, Italy
^cAsan Medical Center, Seoul, South Korea
^dIcahn School of Medicine at Mount Sinai, New York, New York, USA
^eLund University, Lund, Sweden
^fMedStar Washington Hospital Center, Washington, District of Columbia, USA
^gCardiovascular Research Foundation, New York, New York, USA
^hCittà Della Salute e Della Scienza, University of Turin, Turin, Italy
ⁱUniversity of Cagliari, Cagliari, Italy
^jUniversity Medical Center Groningen, University of Groningen, Groningen, the Netherlands
^kHospital Universitario La Princesa, CIBERCV, IIS-IP, Universidad Autónoma Madrid, Madrid, Spain
^lJohns Hopkins University, Baltimore, Maryland, USA
^mBrigham and Women’s Hospital, Boston, Massachusetts, USA
ⁿMedical University of Vienna, Vienna, Austria
^oWashington University School of Medicine, St. Louis, Missouri, USA
^pUniversity of Minnesota, Minneapolis, Minnesota, USA
^qMassachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA

Address for correspondence: Dr Ik-Kyung Jang

Abstract

The concept of high-risk plaque emerged from pathologic and epidemiologic studies 3 decades ago that demonstrated plaque rupture with thrombosis as the predominant mechanism of acute coronary syndrome and sudden cardiac death. Thin-cap fibroatheroma, a plaque with a large lipidic core covered by a thin fibrous cap, is the prototype of the rupture-prone plaque and has been traditionally defined as "vulnerable plaque." Although knowledge on the pathophysiology of plaque instability continues to grow, the risk profile of our patients has shifted and the character of atherosclerotic disease has evolved, partly because of widespread use of lipid-lowering therapies and other preventive measures. In vivo intracoronary imaging studies indicate that superficial erosion causes up to 40% of acute coronary syndromes. This changing landscape calls for broader perspective, expanding the concept of high-risk plaque to the precursors of all major substrates of coronary thrombosis beyond plaque rupture. Other factors to take into consideration include dynamic changes in plaque composition, the importance of plaque burden, inflammatory activation (both local and systemic), healing mechanisms, regional hemodynamic pattern, properties of the fluid phase of blood, and the amount of myocardium at risk subtended by a lesion. Rather than the traditional focus limited to the thin-cap fibroatheroma, the authors advocate a more comprehensive approach that considers both morphologic features and biological activity of plaques and blood. This position paper highlights the challenges to the usual concept of high-risk plaque, proposes a broader definition, and analyzes its key morphologic features, the technological progress of plaque imaging (particularly using intracoronary imaging techniques), advances in pharmacologic therapies for plaque regression and stabilization, and the feasibility and efficacy of focal interventional treatments including preemptive plaque sealing.

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형식Review Paper
게재일2025년 02월 (BRIC 등록일 2025-03-13)
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